Are you currently using braces? (1/12)
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Yes
No
Do you have any veneers or crowns? If yes, can you see them when you smile? (2/12)
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Yes
No
When did you last have a dental cleaning? (3/12)
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Within the past 6 months.
Over a year ago
Not sure
Have you used any of these products before? (Check all that apply) (4/12)
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Whitening Strips or Trays
Whitening Toothpastes or Rinses
Whitening Pens or Gels
Activated Charcoal, Baking Soda, Oil Pulling, Lemon
None of the above
Do any of these apply to you? (5/12)
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Pregnant or nursing
Undergoing chemotherapy or radiation treatment
Using photosensitive drugs
None of the above
You Identify as: (6/12)
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Male
Female
Non-Binary
Other
What is your age range? (7/12)
18-22
23-30
31-40
41-50
51+
What is your preferred time for appointments? (8/12)
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Weekdays during business hours
Weekdays after business hours
Weekends
Do you have any of these conditions? (9/12)
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Cracked enamel
Cervical abrasion
Dentinogenesis imperfecta
Amelogenesis imperfecta
None of the above
What color do you want your teeth to be? (10/12)
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I'm not sure
I want my ideal shade
I want super white teeth
Are you comfortable with receiving structured instructions from our experts both before and after your treatment? (11/12)
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Yes
No
During the program, participants may experience a reduction of up to 32 shades or 85.2% in the yellowing of their teeth. Are you comfortable with this significant change in the color of your teeth? (12/12)
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Yes
No
How did you hear about us? (Optional)
Search engine (Google, Bing, etc.)
Recommended by someone
Social Media
Blog or publication
Other
What’s your best email? (Please use the same email as before)
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What’s your first name?
*
What’s your last name?
*